Multidisciplinary Management of Early Rectal Cancer: What are the Options? Message from the Section of Surgery Meeting at the Royal Society of Medicine, 2 September 2021

The management of early rectal cancer (ERC) is an interesting and controversial topic that generates debate among many professionals who form the multidisciplinary team that provides care for patients with colorectal cancer. Controversies arise from both the diagnosis and management of ERC. There is no agreed definition of what constitutes ERC and there is significant variation in the ‘early’ cancers included in the series reported in the literature. This causes difficulties in comparing outcomes from different series and thus drawing conclusions as to the benefits or otherwise of different treatment options. The vital importance of accurate and consistent pathology and radiology staging and the embedding of experts in these disciplines within the multidisciplinary team cannot be overstated. Most potentially curable rectal cancers are treated with resectional surgery. Although a variety of surgical resection operations are available, the principle of resecting the rectum, with its draining lymph nodes, has been accepted for 50–100 years and there is much evidence of its effectiveness in terms of curing localised rectal cancer. As ERC is localised and, therefore, potentially curable, there has been some hesitation on the part of the surgical community to move to alternative methods of treatment. Each of the resectional operations carries a small, but not insignificant, risk of death and a significant rate of morbidity and impairment of quality of life. For patients with tumours situated low in the rectum, a permanent stoma may be necessary. There is an increasing school of thought that ERC may be treated adequately by less invasive procedures, together with adjuvant modalities of treatment to ensure equivalent cancer-specific survival but with lesser morbidity and improved quality of life. Alternative treatment options to extirpative surgery include external beam radiotherapy followed by ‘watch and wait’ in those who achieved a clinical complete response. Bibi et al. [[1]Bibi S. Edilbe M.W. Rao C. The cost-effectiveness of watch and wait for rectal cancer.Clin Oncol. 2023; 35: 132-137Abstract Full Text Full Text PDF Scopus (1) Google Scholar] and Wyatt et al. [[2]Wyatt J. Powell S.G. Ahmed S. on Behalf of the Merseyside Early Rectal Cancer Network Watch, 2023 Watch and wait in rectal cancer after a complete response to chemoradiotherapy – is it safe and are we doing enough?.Clin Oncol. 2023; 35: 117-123Abstract Full Text Full Text PDF Scopus (1) Google Scholar] expand and discuss this option in this special issue of Clinical Oncology. However, for those with residual disease, there are several options, which include dose escalation with contact X-ray brachytherapy or local resection using transanal endoscopic microscopic surgery. A European multicentre randomised phase III trial, OPERA (Organ Preservation for Early Rectal Adenocarcinoma), evaluated the role of dose escalation using contact X-ray brachytherapy following external beam radiotherapy with chemotherapy. The data from the OPERA trial was presented at ASCO and Myint et al. [[3]Myint A.S. Dhadda A. Stewart A. Mills J. Sripadam R. Rao C. et al.on Behalf of UK Papillon Team and International Contact Radiotherapy Network (ICONE). The role of contact X-ray brachytherapy in early rectal cancer – who, when and how?.Clin Oncol. 2023; 35: 87-96Abstract Full Text Full Text PDF Scopus (1) Google Scholar] share the results within this special issue. Likewise, Bach [[4]Bach S.P. STAR-TREC is an international three-arm multicentre, partially randomised controlled trial incorporating an external pilot.Clin Oncol. 2023; 35: e107-e109Abstract Full Text Full Text PDF Scopus (1) Google Scholar] share data on his ongoing STAR-TREC trial randomising between long-course chemoradiotherapy and short-course radiotherapy followed by transanal endoscopic microscopic surgery for those with residual tumour. The jury is still out. The Sections of Surgery and Coloproctology at the Royal Society of Medicine (RSM) are multidisciplinary groups of professionals with an interest in improving patient care, particularly for common conditions such as rectal cancer. In September 2021, we were delighted to be able to host one of the first in-house meetings at the RSM post-lockdown and to welcome faculty and delegates from around the world, both in person and online. Clinicians, researchers, trialists and opinion leaders were able to come together to learn from each other and debate the issues around current and future methods of treatment. We were particularly pleased to have the contribution of Mark Davies-Cousins [[5]Davies-Cousins M. From a patient choice perspective: nearly 20 years on, has patient choice improved or was I just lucky?.Clin Oncol. 2023; 35: 130-131Abstract Full Text Full Text PDF Scopus (1) Google Scholar], a former patient with ERC, who gave an entertaining, but thought-provoking, account of the realities of facing the difficult decisions that have to be made and the consequences of the treatment required in this situation. We are also grateful to Clinical Oncology for the opportunity to publish the proceedings of this meeting and hope that this will allow dissemination to a wider audience. In summary, ERC remains a curable disease, but there is a balance to be struck between radicality of treatment and the likely consequences for morbidity and mortality. Several clinical trials are now in progress to address these issues and it is to be hoped that patients will soon be able to be assured of excellent cancer-related outcomes while preserving bowel function, body image and other quality of life indicators. More importantly, the data from these randomised trials will provide us with much needed information to give to our patients, so that they have full information on the pros and cons of different options before giving their consent to a particular treatment option. After all, they are the ones who must live with the consequences of treatment, as Mark so eloquently described. We hope that the information from our RSM meeting on the multidisciplinary management of ERC has provided the colorectal community with some challenging thoughts to enable us to reconsider how we should treat ERC in the future. The authors declare no conflicts of interest.